Medicare/Medicaid Fraud in Detroit

The greater Detroit area has become a primary target in the government’s ongoing battle against Medicare/Medicaid fraud. Due to Detroit’s large number of retirees, the city has one of the largest numbers of Medicare beneficiaries nationwide. This also means that Detroit health care providers’ Medicare/Medicaid billing rates are among the highest in the country, and this has led the Centers for Medicare and Medicaid Services (CMS) to keep a close eye on local Medicare/Medicaid providers.

In fact, Detroit is one of only nine areas in the nation in which the federal government established a special task force to monitor, investigate, and prosecute Medicare/Medicaid fraud. This task force, known as the Health Care Fraud Prevention and Enforcement Action Team (HEAT), is a coordinated federal task force composed of prosecutors from the Department of Justice (DOJ), the Department of Health and Human Services (HHS), the Office of Inspector General (OIG), the Federal Bureau of Investigation (FBI), and other federal agencies.

As a result, health care service providers and other businesses involved in Detroit’s health care industry in Detroit must be especially vigilant to avoid any suspect practices that could trigger a HEAT Medicare/Medicaid fraud investigation.

What is Medicare/Medicaid Fraud?

Medicare/Medicaid Fraud Explained

Medicare/Medicaid fraud is a federal offense that involves submitting false or fictitious claims for reimbursement to CMS. There are varying forms of Medicare/Medicaid fraud. Fraudulent reimbursement claims can potentially violate a number of different federal statutes. These include:

False Claims Act – The False Claims Act prohibits knowingly submitting false statements or making misrepresentations of fact in order to obtain payments to which you are not entitled under a federal health care benefit program (such as Medicare/Medicaid).

Anti-Kickback Statute – The Anti-Kickback Statute prohibits knowingly soliciting, paying, or accepting any form of compensation or reward for a referral for services, medication, supplies, or equipment for which you receive reimbursement under a federal health care benefit program.

Physician Self-Referral Laws (Stark Law) – The Stark Law prohibits physicians from making certain referrals to entities in which the referring physician or an immediate family member has an ownership or financial interest.

Medicare/Medicaid fraud can also cause you to be charged under the Social Security Act and various provisions of the U.S. Criminal Code, as well.

Common Forms of Medicare/Medicaid Fraud

The following are all examples of some of the most common forms of Medicare/Medicaid fraud. While each form is different, what they all have in common is that they all involve seeking to illegally obtain reimbursement under a federal health care program.

Common forms of Medicare/Medicaid fraud include:

Billing for services that were never performed (“phantom billing”);

Billing for supplies and equipment that were not actually purchased;

Billing for services that were not medically necessary;

Billing for supplies and equipment that were medically unnecessary;

Obtaining fraudulent certifications for services that were medically unnecessary (a common allegation in home health and hospice fraud investigations);

Civil and Criminal Penalties for Medicare/Medicaid Fraud in Detroit, Michigan

The potential penalties in a Medicare/Medicaid fraud investigation will depend on whether the investigation is civil or criminal in nature. However, generally speaking, targets of Medicare/Medicaid investigations may be exposed to recoupment requests, non-payment of future claims, civil fines of up to $11,000 per false claim, exclusion from federal health care programs (including Medicare/Medicaid ), treble damages, legal fees, criminal fines, and incarceration. The possible prison sentences for Medicare/Medicaid fraud include:

Medicare/Medicaid fraud – Up to 10 years in prison for each count of fraud;

Medicare/Medicaid fraud resulting in serious bodily injury – Up to 20 years in prison (common in cases involving reimbursement requests for counterfeit or excessive medication); and

Medicare/Medicaid fraud resulting in death – Life imprisonment.

Physicians and other medical professionals in Detroit, Michigan who are accused of Medicare/Medicaid fraud can face the loss of their medical licenses and hospital privileges.

Defending Yourself in the Face of a Medicare/Medicaid Fraud Investigation

Early Intervention is Critical

In a Medicare/Medicaid fraud investigation, one of the most important tasks for your defense team is fighting to keep the investigation civil. This keeps prison time off of the table, and can greatly reduce the overall scope and consequences of the investigation.

To do this, early intervention is critical. You need to hire a Medicare/Medicaid fraud defense attorney right away who can open a dialogue with the prosecutor assigned to your investigation and get answers to key questions like:

Is the case civil or criminal?

What prompted the investigation?

What is the case about?

Who else is under investigation?

Which agencies are involved?

What is the government’s ultimate goal?

How can the issue be resolved?

At Oberheiden, P.C., we strive to provide our clients these answers within the first hours of our engagement.

Statutory Defenses to Allegations of Medicare/Medicaid Fraud

A thorough analysis will often reveal several favorable defenses that are available under the statutes implicated in the investigation. For example, both the Stark Law and the Anti-Kickback statute contain a number of safe-harbor provisions. The Stark Law contemplates certain services that fall outside of the “designated health services” covered by the statute’s prohibitions on self-referrals.

Key Defenses in a Criminal Medicare/Medicaid Fraud Prosecution

If your situation is such that a criminal case is unavoidable, the government still has the burden of proving your guilt beyond a reasonable doubt. This requires securing sufficient evidence to prove that you committed an illegal act and that you did so with criminal intent.

Intentional health care fraud In Detroit, Michigan is rare. In our professional experience, most incidents that prompt federal Medicare/Medicaid investigations result from basic organizational and human errors. Medicare/Medicaid rules and regulations are exceedingly complex, and health care providers will often make honest mistakes because their primary focus is on caring for their patients. Rapid growth can lead to an increase in mistakes, as well. Some of the most common culprits include things like:

Hiring unqualified staff;

Inadequate supervision;

Overreliance on delegation or outsourcing;

Structural deficits and organizational mistakes;

Mistakes resulting from oversight or feeling overwhelmed; and

An ineffective Medicare/Medicaid compliance program.

These types of mistakes should not result in criminal penalties. Unfortunately, too many Detroit medical professionals and business owners simply assume that they are guilty because they are under investigation and accept penalties that they do not deserve. If you are facing a criminal investigation, our defense attorneys will fight vigorously to secure a favorable outcome:

Getting the case dismissed;

Avoidance of criminal charges;

Retaining your professional license;

Civil fine, but no criminal plea;

Reducing felony charges to a misdemeanor; and

No jail time

Choosing the Right Defense Lawyer in Detroit, Michigan

Given the potential catastrophic risks of a Medicare/Medicaid fraud investigation, you need a qualified defense team on your side. So, what type of lawyer (or, preferably, lawyers) should you choose?

Limitations of Choosing a Health Care or Criminal Lawyer

Medicare/Medicaid fraud cases are extremely complex, both in terms of the general health care law aspects and the Medicare/Medicaid -specific issues involved. Moreover, in Medicare/Medicaid fraud cases, prosecutors will often also seek charges for mail fraud, wire fraud, tax evasion, money laundering, and a number of other serious federal offenses. A conviction on multiple charges could mean spending decades behind bars.

Unfortunately, most Detroit, Michigan criminal lawyers lack the health care knowledge necessary to effectively defend clients against complex Medicare/Medicaid fraud investigations. Similarly, while health care lawyers may be able to competently handle the Medicare/Medicaid aspects of your case, they will most likely lack the experience and training necessary to negotiate effectively with the federal prosecutors assigned to your investigation.

The Right Choice: A Team of Health Care Fraud Defense Lawyers

Health care fraud defense lawyers combine the best qualities of both criminal defense lawyers and health care lawyers. An experienced health care fraud defense lawyer will know the Medicare/Medicaid system inside and out, and will be able to engage with federal prosecutors to prevent clients from facing avoidable civil and criminal liability.

Unlike other defense firms, at Oberheiden, P.C. we truly take a team approach to defending our clients. When you choose us, our senior defense attorneys and former federal prosecutors will work together on your case, pooling their resources and using aggressive, proven defense tactics to help you avoid civil or criminal charges.

Detroit Medicare/Medicaid Fraud Defense Attorneys

Dr. Nick Oberheiden is a Harvard-trained and internationally educated health care fraud defense attorney. He has successfully represented health care executives, business owners, public officials, physicians, and lawyers in high profile prosecutions, people accused of political corruption, been involved in government investigations, and assisted with media campaigns, including 60 Minutes. Dr. Oberheiden is often sought out to help end federal investigations before they result in criminal charges. He also leads internal investigations, implements corporate compliance programs, and teaches U.S. criminal law and federal litigation in the United States and abroad.

Lynette S. Byrd is a former Assistant United States Attorney (AUSA). Ms. Byrd’s Detroit clients greatly benefit from her former experience of working with the Department of Justice. She prosecuted health care fraud, Anti-Kickback violations, False Claims Act, and Stark violations on behalf of the United States. This former experience has prepared her to regularly argue federal matters for her clients.

We are available every day of the year. You can call us directly or complete our contact form to request a free consultation.

This information has been prepared for informational purposes only and does not constitute legal advice. This information may constitute attorney advertising in some jurisdictions. Reading of this information does not create an attorney-client relationship. Prior results do not guarantee similar future outcomes. Oberheiden, P.C. is a Texas firm with headquarters in Dallas. Mr. Oberheiden limits his practice to federal law.

Contact Us

Disclaimer

CAUTION - Please note: Do not send us any confidential information. By clicking “I accept the terms and conditions” you agree that our review of the information contained in your e-mail and any attachments will not create an attorney-client relationship between you and our firm or any lawyer in our firm and will not prevent any lawyer in our firm from representing a party in any matter where that information is relevant, even if you submitted the information in a good faith effort to retain us, and, further, even if that information is highly confidential and could be used against you.

Contact Us Today

Oberheiden, P.C. is headquartered in Dallas, Texas, and it assists clients with audits, investigations, and trial work nationwide. Call one of us today and benefit from our experience and industry knowledge in a free and confidential consultation.

NOTICE:All visitors to this Website are informed that Oberheiden, P.C. (“Firm”) affiliates with independent and separate attorneys (“Local Counsel”) and their respective law firms on a case by case basis. If and when this applies to a particular client, we will disclose the details to client in writing for their approval.

In some cases, pursuant to Rule 7.04 of the Texas Disciplinary Rules of Professional Conduct and the equivalent in other jurisdictions, a case is referred to a Local Counsel, the Firm will not participate in the representation. In such a case, client will sign an engagement exclusively with the Local Counsel.